January 2010

Most first time North Carolina Workers’ Compensation claimants find themselves ovewhelmed by the Byzantine claims process. To make things easier for you, we’ve put together this quick guide to explain the basic players who deal with North Carolina Workers’ Compensation claims and injury management.

1. Employee

This is you. A worker who gets injured while executing a job related duty can be eligible for North Carolina Workers’ Compensation.

2. Employer

Your boss or your company is technically be known as the “employer.” If you work for yourself, and you have Self Employment Workers’ Compensation Insurance, you may be both the employee and the employer. Many employers are required by law to carry North Carolina Workers’ Compensation policies. These policies pay out to injured claimants; thus, the money does not come directly from the employers/company’s pockets. Another technical name for the employer is the “Insured.”

3. Insurance Company

The insurance company issues policies to employers to cover them in the event that an employee (such as you or a co-worker) gets injured on the job and requires money to pay for medical services, rehabilitation, and time off of work. Different states have different laws regarding Workers’ Comp Insurance Coverage. If you have specific questions regarding how North Carolina Workers’ Compensation Insurance companies must behave, speak with a veteran attorney or call the North Carolina Industrial Commission (NCIC).

4. Insurance Broker/Agent

A Broker or Agent acts as a liaison between the Insurance Company and the Employer. A broker typically tries to sell services to employers. The Broker can also act as a consultant and risk benefit analyst for employers.

5. Claims Administrator

A third party administrator, also known as a TPA, manages claims, adjusting them per settlement arrangements. Some insurance companies outsource their work to these independent agencies. TPAs also must act in accordance with North Carolina laws.

6. Doctor/Rehabilitation Specialist

The Physician and/or Rehab Specialist play critical roles in the injury management process. Obviously, if you are hurt on the job, a medical doctor must examine you and attest to your state and degree of injury before you can collect North Carolina Workers’ Compensation benefits.

7. Attorney

A North Carolina Workers’ Compensation Attorney can help you resolve questions you have regarding eligibility, benefits, settlement arrangements, insurance negotiations, and so forth. Most good attorneys will provide free, confidential consultations to answer your questions and concerns. Take advantage of this opportunity to learn more about the lawyer’s services, fee structure, track record, and credentials.

Elevated North Carolina Workers’ Compensation costs concern everyone in the “employment ecosystem” – small business owners, employees, government agencies, insurance companies, and physicians alike. To bring down costs across the board, however, requires a holistic approach to problem solving. In this article, we will speculate about remedies that could be applied throughout this “ecosystem” – at little to no cost to employers, insurers, or employees.

1. Put in place systematic solutions to common workplace ergonomic problems. How many North Carolina workers’ compensation cases begin at the keyboard? Carpel tunnel syndrome, repetitive stress injuries, and other soft tissue injuries abound in North Carolina – many of them no doubt due to bad workstation ergonomics. An employer can mitigate against risk of repetitive stress injuries by investing in more economic keyboards, for instance, more tailored workstations, and a program of regular breaks and stressing. The cost of such a proactive “war” against repetitive stress injuries would be minimal, and the benefits would no doubt be long lasting. Workers who are not exhausted from keyboarding and other repetitive tasks can work longer hours (thus making up any theoretical costs of ergonomic modifications). Fewer injuries would mean lower North Carolina Workers’ Compensation insurance premiums.

2. Better Alert and Response System to Control North Carolina Workers’ Compensation Fraud. As the old saying goes, a few bad apples can spoil the bunch. Everyone loses when people cheat the system. But how do you get people the stop cheating? This is the $64,000 question. Better monitoring of claims might be a theoretically good solution, but when you incentivize insurance companies to look for fraud, these companies inevitably will turn up “false positives.” I.e., they will harass people who are legitimately injured – trying to get them to admit that they are not actually hurt. This is obviously terrible, and it results in many tragedies, some of which we have reported on this blog.

A better solution might be to build in a more robust tracking system to make sure that claimants stay honest. In addition, insurance companies and employers must recognize and respect the claimants who are actually hurt and go the extra mile to help them.

3. Involve physicians in more holistic patient care. The fractured approach to patient healthcare no doubt exacerbates many medical problems. If a patient sees four doctors, chances are that each physician will require separate paperwork, and that the doctors will not communicate with one another about the patient. This needs to change. Implement across the board holistic treatment for injured patients, and we will see much better health care. This is obviously an enormous task. But if we really want to bring down North Carolina Workers’ Compensation costs, we need to start treating patients as whole people — and not just as carriers of individual symptoms they present with.

4. Better, more thorough and more regular data analysis of North Carolina Workers’ Compensation cases.

Organizations like the North Carolina Industrial Commission (NCIC) and other government agencies do track serious injuries and deaths at NC workplaces. But the amount of data that’s mined and shared about these accidents is extremely small, maybe even negligible, compared with what could be mined. We need to gather much more information – much more detailed analyses of various injuries and incidents. We must be able to share that information not only with government agencies, insurance companies, and fellow employers, but also with employees. Do this kind of analysis, and we will no doubt be amazed at the kind of improvisations and “band-aid” solutions that emerge.

If you or somebody you love has been hurt or needs help with North Carolina Workers’ Compensation issues, connect with a qualified veteran attorney near you for a confidential consultation.

A recent report released by the California Workers’ Compensation Institute has many experts and consultants who specialize in North Carolina workers’ compensation quite concerned. The CWCI found that just 3% of doctors who treat workers’ comp patients in the Golden State prescribe over 55% of the “Schedule II” medications, which include potentially addictive drugs like methadone, codeine, and fentanyl. The report, Prescribing Patterns of Schedule II Opioids in California Workers’ Compensation, found a variety of disturbing findings, including:

• The top one percent of hurt workers ingested 25 times more medication than did the average workers’ compensation patient. • 279 physician prescribers drove two-thirds of all drug-related payments • Over 50% of Schedule II drug claims involved minor back pain – certainly a troubling issue, but not an issue that necessarily requires strong medications. • Schedule II drugs prescribed in CA skyrocketed from just 1.4% in 2005 to 7.2% by 2009. • Payment for Schedule II drugs also increased by over 500%.

Dr. Arnold Milstein, the leader of Stanford University’s Clinical Excellence Research Center, explained why regulatory agencies may not be putting the brakes on what’s clearly an over-prescription problem: “The State Medical Licensing Board is horribly underfunded in terms of stopping these obviously crazy prescribing patterns by a small percentage of doctors.”

Another expert, Joe Paduda of Health Strategy Associates, explained why physicians might take unfair advantage of the system: “The workers’ comp industry is a very soft target for healthcare providers and other people who want to take advantage of regulatory or other loopholes.”

The California system, apparently, is set up in such a way that patients get encouraged to go the prescription med route instead of trying alternative, non-medication related modalities, such as physical therapy and strength training.

States differ tremendously in their workers’ comp programs. And no North Carolina institution has done a similarly thorough study on Schedule II workers’ comp prescriptions. But it shouldn’t come as that much of a surprise that a minority of doctors causes the most abuse. The so-called “Pareto principle” – also known as the 80-20 Rule – is a well-established economic principle. It suggests that, in any given population, a minority of participants will drive the majority of results. For instance, if you own a small business, 20% of your clients will yield 80% of your work. 20% of your clients will also yield 80% of your problems. And so forth. So the fact that a small minority of doctors caused the majority of the Schedule II drug abuse shouldn’t be too much of a surprise. Indeed, data should find a similar pattern here in North Carolina.

North Carolina workers’ compensation experts are cheering some new numbers released about accidental workplace deaths in the state. According to 2009 statistics compiled by the state’s Department of Labor, only 35 workers across North Carolina were killed on the job last year. Eight of these deaths resulted from explosions or fires; six resulted from projectile objects; five resulted from crushing injuries; and three deaths resulted from electrocution. June, 2009 saw the highest number of workplace fatalities in the state — due to the Slim Jim plant explosion that occurred early in that month. According to the DOL, no one was killed in April, 2009.

More good news: the DOL numbers have shown a steady but significant decline in the past several years. In 2008, 56 workers died on the job. In 2007, 45 workers were killed.

The rate of injuries and illnesses on the job also seems to be in decline. Back in 2004, around 4.1 workers out of 100 reported some kind of injury or illness. That number dropped to 4 out of 100 in 2005. By 2007, that number was down to 3.7 out of 100. And last year, the number dropped again to 3.4 out of 100.

To what do North Carolina workers’ compensation experts credit this improvement in safety and decline in illnesses and injuries? Like all issues of epidemiology, it can be very difficult to tease out causation from data like these. Sure, experts may point to safety improvements in this or that industry, and some can suggest that better sanitary measures taken at work or improvements in safety equipment might be responsible for some of the decline in deaths and illnesses. But without a rigorous comprehensive scrutiny of the evidence (and even then, you can probably question the validity of any findings), no one will likely be able to pinpoint where state workers and employers are “going right.” That being said, however, the DOL will no doubt continue to track trends to look for meaningful associations that might suggest potential programs, infrastructure changes, or strategies to help keep NC workers safe and healthy.

If you or a loved one has suffered an injury at work — or if a family member was unfortunately killed while on the job — you may be eligible for substantial North Carolina workers’ compensation benefits. However, given how complicated the benefits disbursal system can be, it may behoove you to connect with an attorney who specializes in this kind of work to ensure that you get the payments you deserve — when you deserve them — and that you don’t suffer any undue harassment or stalling on the part of insurance companies or employers.

For extensive and detailed North Carolina workers’ compensation assistance, look to either the North Carolina Industrial Commission (NCIC) or to a reputable, experienced attorney to handle questions about benefits, disputes with employers or insurance companies, and other strategic or tactical concerns.

This essay will give you some insight into a question that many injury workers have — namely, whether an occupational injury or illness acquired will be compensable under the law.

What is occupational disease?

Technically, it is a condition that is caused/exacerbated by a particular kind of job or job process — or is characteristic of a certain profession. For instance, chimney sweeps in the days of old used to get all sorts of lung ailments — the occupational diseases of chimney sweeping.

A disease must meet four parameters in order for it to be considered “occupational.”

1. The disease has to be “peculiar” to a kind of work or industry.

As we’ve mentioned in our previous example, certain exotic lung ailments would be peculiar to people who spend ten to twelve hours a day cleaning chimneys. Similarly, individuals who operate sewing machines for twelve to fourteen hours a day, for instance, may experience repetitive stress injuries due to repetitious fine movement of the fingertips. Conversely, a sewing operator would have a hard time proving that her type 1 diabetes is an occupational disease, since diabetes does not show an exaggerated prevalence among her coworkers.

2. The employee must get that disease or illness while working in a particular line of work.

Consider the case of a concert violinist who plays in a philharmonic who develops severe burns to her back. Unless she got the burns while engaged in the course of her work — for instance, maybe she had an accident in the kitchen or got electrocuted or got caught in a fire — she cannot claim that the burns resulted directly from an occupational disease.

3. The occupation needs to present a hazard.

To build on our previous example, our violinist might be at for developing soft tissue injuries, such as tennis elbow, rotator-cuff damage, repetitive stress injury, etc. After all, playing the violin requires hours and hours of repetitious movements of the hands, fingers, and arms.

4. The incidence of the disease is higher than it is in the normal population.

As we mentioned earlier, chimney sweeps tend to develop lung ailments at a much more exaggerated rate than do people in other walks of life. Violinists and sewing machine operators, likewise, suffer a higher than average incidence of repetitive strain and myofascial problems.

If you, a friend, or coworker suffers from occupational disease, and you need help with your North Carolina workers’ compensation benefits, a reputable attorney can provide you with guidance to ensure that the insurance companies and your employers treat you fairly.

However, in some cases, an insurance company or employer can act so egregiously that the only recourse is to pursue recompense in court. Here are some things to consider when debating whether or not to go to trial over your North Carolina workers’ compensation matter.

1. The process can be time consuming.

The judicial process is slow, sometimes aggravatingly so. You may be called into the courtroom multiple times over the course of months. You and your attorney alike may have a lot of logistical work to do to prepare. It can be months before a judge weighs in. So prepare yourself for a lot of starts and stops — and budget your time and patience accordingly.

2. Prepare for potentially brutal tactics.

Insurance companies can be quite aggressive — and even nasty — when defending decisions to deny coverage or to refuse to pay out a policy. In some cases, companies have actually videotaped plaintiffs on the sly in the hopes of catching them “acting uninjured.” These companies argue that they do this to prevent fraudulent claims, but if you are legitimately injured, this can seem to be quite a heartless tactic. Be prepared for assaults on your word and character, and work closely with your North Carolina workers’ compensation attorney to anticipate these tactics and defend against them accordingly.

3. How you dress and act in the courtroom counts.

In a perfect world, a trial would deal specifically with issues of law and nothing else. But human beings are susceptible to persuasion. How you conduct yourself in the courtroom, how you dress, how you articulate your stance, and how prompt you are to court proceedings can all dramatically influence a judge’s decision. To give yourself the best chances, dress appropriately (and soberly), be polite and attentive to everyone, think through your thoughts before speaking them out loud – particularly when you’re addressing the judge, and mentally rehearse your trial prior to the date, so you can envision the best possible outcomes.

4. Prepare both for victory and for loss.

To make the waiting period less excruciatingly stressful, anticipate both victory and defeat scenarios, and focus on tasks immediately at hand to avoid getting caught up in needless speculation. The judge’s decision will come, and when it does come, you (along with your lawyer) can piece together your best next steps of action.

5. Even if a verdict goes your way, the insurance company may still watch you.

Many North Carolina workers’ compensation claimants win at trial only to find themselves in hot water months or even years later. Insurance companies can follow you to make sure that you are as injured as you say you are. If you give an opening, companies may retroactively attack your claim. Again, there have been instances of insurance companies videotaping claimants to try to catch them in the act of “being healthy” in order to negate a claim retroactively.

All this being said, one of the best strategies to ensure victory is to connect with a reputable, trial proven, and results driven North Carolina workers’ compensation lawyer as quickly as possible to create a prepared and proactive strategy.

Here is a brief primer on North Carolina workers’ compensation fraud — including relevant laws passed by the North Carolina General Assembly as well as information, implications, and a toll-free hotline for fraud investigation.

Laws In 1994, the state assembly passed the Workers’ Compensation Reform Act, which included statute 97-88.2 (outlining punishments for misrepresentation in a North Carolina workers’ compensation filing) as well as statute 97-88.3 (outlining punishments for healthcare providers who fail to follow the law.)

The following year, the state assembly changed statute 97-88.2 and empowered the North Carolina Industrial Commission (NCIC) to look into fraud violations of the 1994 WCRA.

In 1997, the North Carolina Assembly passed House Bill 618, which further amended two key statutes – 97-88.2 and 97-94 — to spell out increased penalties for fraud and misrepresentation under the Workers’ Compensation Act.

Today, the NCIC operates a hotline at (888) 891-4895 from Monday through Friday during normal business hours.

Individuals who commit North Carolina workers’ compensation fraud imperil the whole system. Fraud drains millions of dollars that would otherwise go to claimants with legitimate problems. That being said, not all cases are cut and dried. Some individuals may accidentally commit North Carolina workers’ compensation fraud simply because they fail to fill out paperwork properly or fail to follow bureaucratic protocol. It’s not that they try to cheat the system, in other words; it’s that they do not understand how to operate within it effectively.

This isn’t to say that there are not some bad eggs out there who intentionally game the system. However, if you or a family member has been accused of this crime — or if you’re in need of other kinds of assistance filing or moving forward with your North Carolina workers’ compensation claim — it may behoove you to connect with a knowledgeable attorney right away to discuss your concerns in confidence. A free consultation with a reputable attorney can put you on a strategic path to maximize your benefits and minimize your hassle.